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PROOF OF INSURANCE (2020) CLOSED 0 DATE(MMIDDIYYYY)
e6 CERTIFICATE OF LIABILITY INSURANCE I 02r28r2019
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
TACT
PRODUCER 951-656-2409 951-281-3900 NME Patrick McCarrY
dNF McCarry Insurance Services Lic. OD20867 [1P0CH_.No,Axl)�951-656 X409 (WjW:951-281-3900
19510 Van Buren Blvd. a{ass Prtc arhoommcrn.............mm.........................___. ...
Ste. F3-142 .... INSURER(S)gAFFQRDINGCOVERAGE` ! wuca
Riverside, CA 92508 INSURERA:United National Insurance Comp _V 13064
INSURED 310-548-9292 310-548-9195 mINSURERS:WeSCO Insurance Company 25011
'Berg &Associates, Inc. INSURERC:National Union Fire Insurance Co. 19445
dba: Berg Engineering Service INSURER D:Ins. Co. of the State of Pennsvlvan 19429
302 W. 5th Street, Suite 210 I.NSURER..E.,.,U.,.Se....S.Pecialty_L.nsurance C_o ?pany..............m...._...29599.,._ ,......
San Pedro. CA 90731 INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:02
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUEDTO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
TYPE OF INSURANCE __�. "` -_._.. ___ ._.._( .._.__ .... .,. ..
Iryl$}t_ . ADDi.$UBfF2 PO'LICY' 'FF�'+POLICY ExP
LTR �IVn POLICY NUMBER {MMJODd'YYY'Yp (N4MI'DDrYYYY1 LIMITS
GENERAL LIABILITY EACH OCCURRENCE $1.Qo0.00Q,,,,_
A COMMERCIAL GENERAL LIABILITY D�GiCYkIcdlEtl_
CLAIMS-MADE ✓ OCCUR L7221 197-A 03/01/2019 03/01/2020 MED EXP(Any one nersonl $ 0
PERSONAL&ADV INJURY $1900 00
GENERAL AGGREGATE _$_,2 00AQ00
GEN"L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $Included
POLICY' PER �'LOC $
AUTOMOBILE LIABILITY � ', �L I�,Ep11 SINGLE L11111T _t!1_ ,a.-_.
W WPP1611478 01 03/01/2019 o3101r2o2o 1 Q�p 000__,.,__
B V( ANYAUTL') BODILY INJURY(Per person) $,
ALL OWNED SCHEDULED
AUTOS AUTOS BODILY INJURY(Per accident) $
AUTOS ._.._..._.._.. _...,
NON-OWNED ��'ROPERTY DA{MAGE
HIRED AUTOS $
Medical $5.000
UMBRELLA LIAB OCCUR 03/01/2019 03/01/2020 EACH OCCURRENCE $9.000,000
C , Excessune CLAIMS.M{ADE BE 034215041 AGGREGATE $9,000,000
DED RETENTIONS0 r�yPr/rod/C.O. Aggreq. $9.000,000
ANY PROPRIETORIPARTNERIEXECCUTIVE E.L,,E H ACC DENT OT
WORKERS COMPENSATION H.
AND EMPLOYERS'LIABILITY —A -`CL1Mff'S ER_
Y r N 03/01/2019 03101/2020 $1 000 OQQ
D OFFyFICERIMEMBER EXCLUDED? 1 NIA WC012332162-02
QQQ
DESCRIPTION,OFOPERATIONS below E.I. DISEASE
POLICYLIMIT.•..,,.1..QQQ,.�.Qt� ..,
(Mandatory ) OYES
L
Liability each claim, $1,000,000
E Professional Liability USS 19 29483 03101/2019 03/01/2020 iAggregate: $2,000,000
f
DESCRIPTION OF OPERATIONSI LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more apace Is required)
USL&H coverage included as part of above referenced workers compensation insurance policy.
CERTIFICATE HOLDER CANCELLATION
City of LI Segundo
Public Works SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
350 Main St. ACCORDANCE WITH THE POLICY PROVISIONS.
EI Segundo, CA 90245
AUTHORIZED REPRESENTATIVE ° /
©1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD
POLICY NUMBER: L7221197-A COMMERCIAL GENERAL LIABILITY
CG 20 10 04 13
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES O
CONTRACTORS - SCHEDULED F SO O
ORGANIZATION
This endorsement modifies insurance provided under the following.
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name Of Additional Insured Person(s)
Or Organization(s) Location(s)Of Covered Operations
City of EL Segundo officers, officials, employees, City of El Segundo
agents, representatives and certified volunteers Public works
350 Main St.
El Segundo, CA 90245
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
A. Section II — Who Is An Insured is amended to B. With respect to the insurance afforded to these
include as an additional insured the person(s) or additional insureds, the following additional
organization(s) shown in the Schedule, but only exclusions apply:
with respect to liability for "bodily injury", "property This insurance does not apply to "bodily injury" or
damage or personal and advertising injury "property damage"occurring after:
caused, in whole or in part, by:
1. Your acts or omissions; or 1. All work, including materials, parts or
equipment furnished in connection with such
2. The acts or omissions of those acting on your work, on the project (other than service,
behalf; maintenance or repairs) to be performed by or
in the performance of your ongoing operations for on behalf of the additional insured(s) at the
the additional insured(s) at the location(s) location of the covered operations has been
designated above. completed;or
However: 2. That portion of "your work" out of which the
injury or damage arises has been put to its
1. The insurance afforded to such additional intended use by any person or organization
insured only applies to the extent permitted by other than another contractor or subcontractor
law; and engaged in performing operations for a
2. If coverage provided to the additional insured is principal as a part of the same project.
required by a contract or agreement, the
insurance afforded to such additional insured
will not be broader than that which you are
required by the contract or agreement to
provide for such additional insured.
CG 2010 0413 ©Insurance Services Office, Inc., 2012 Page 1 of 2
C. With respect to the insurance afforded to these 2. Available under the applicable Limits of
additional insureds, the following is added to Insurance shown in the Declarations;
Section 111—Limits Of Insurance: whichever is less.
If coverage provided to the additional insured is This endorsement shall not increase the
required by a contract or agreement, the most we applicable Limits of Insurance shown in the
will pay on behalf of the additional insured is the Declarations.
amount of insurance:
1. Required by the contract or agreement;or
Page 2 of 2 ©Insurance Services Office, Inc., 2012 CG 2010 0413
POLICY NUMBER: L7221197-A COMMERCIAL GENERAL LIABILITY
CG 20 01 0413
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
PRIMARY ASI D NONCONTRIBUTORY -
OT INSURANCE CONDITION
ENDORSEMENT
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART
The following is added to the Other Insurance (2) You have agreed in writing in a contract or
Condition and supersedes any provision to the agreement that this insurance would be
contrary: primary and would not seek contribution
Primary And Noncontributory Insurance from any other insurance available to the
This insurance is primary to and will not seek
additional insured.
contribution from any other insurance available
to an additional insured under your policy
provided that:
(1) The additional insured is a Named Insured
under such other insurance;and
THIS ENDORSEMENT APPLIES TO THE
FOLLOWING ENTITY:
City of El Segundo officers, officials, employees, agents, representatives,
and certified volunteers.
CG 20 01 04 13 ©Insurance Services Office, Inc., 2012 Page 1 of 1
POLICY NUMBER: L7221197-A COMMERCIAL GENERAL LIABILITY
CG 24 04 05 09
WAIVER OF TRANSFER OF FIGHT'S OF' RECOVERY
AGAINST OTHERS TO HS
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART
SCHEDULE
Name Of Person Or Organization:
ALL WRITTEN CONTRACTS
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
The following is added to Paragraph S. Transfer Of
Rights Of Recovery Against Others To Us of
Section IV—Conditions:
We waive any right of recovery we may have against
the person or organization shown in the Schedule
above because of payments we make for injury or
damage arising out of your ongoing operations or
"your work" done under a contract with that person
or organization and included in the "products-
completed operations hazard". This waiver applies
only to the person or organization shown in the
Schedule above.
CG 24 04 05 09 0 Insurance Services Office, Inc., 2008 Page 1 of 1 0
POLICY NUMBER: WPP1611478 01 COMMERCIAL AUTO
CA990187 0715
This Endorsement Changes The Policy. Please Read It Carefully
BUSINESS UTO COVERAGE EXPANSION
ENDORSEMENT
This endorsement modifies insurance provided by the following:
BUSINESS AUTO COVERAGE FORM
With respect to coverage provided by this endorsement, the provisions of the COVERAGE FORM apply
unless modified by the endorsement.
A. Newly Acquired or Formed e. An"employee"of yours is an "insured"
Organizations, Employee Hired Car while operating an "auto"hired or rented
Liability and Blanket Additional Insured under a contract or agreement in that
Status for Certain Entities. "employee's"name,with your
Item 1.Who is an Insured of Paragraph A. permission, while performing duties
Coverage under SECTION II—COVERED related to the conduct of your business.
AUTOS LIABILITY COVERAGE is f. Any person or organization you are
amended to add: required by written contract or
d. Any organization you newly acquire or agreement to name as an additional
form, other than a partnership,joint "insured", but only with respect to
venture or limited liability company, and liability created in whole or in part by
over which you maintain ownership of a such agreement.
majority interest(greater than 50%),will B. Increase Of Loss Earnings Payment
qualify as a Named Insured; however, Subpart(4)of a.Supplementary Payments
(1) coverage under this provision is of Item 2. Coverage Extensions of
afforded only until the 1801'day Paragraph A. Coverage under SECTION II
after you acquire or form the —COVERED AUTOS LIABILITY
organization or the end of the policy COVERAGE is amended to read:
period, whichever is earlier; (4) We will pay reasonable expenses
(2) coverage does not apply to "bodily incurred by the"insured"at our
injury", "property damage"or request, including actual loss of
"covered pollution cost or expense" earnings up to$1,000 per day
that results from an"accident"which because of time off from work.
occurred before you acquired or C. Fellow Employee Injured By Covered
formed the organization; and Auto You Own Or Hire
(3) coverage does not apply if there is Item 5. Fellow Employee of Paragraph B.
other similar insurance available to Exclusions under SECTION II—COVERED
that organization, or if similar AUTOS LIABILITY COVERAGE is
insurance would have been amended to add:
available but for its termination or
the exhaustion of its limits of This exclusion does not apply if the"bodily
insurance. injury"results from the use of a covered
"auto"you own or hire. Such coverage as
This insurance does not apply is afforded by this provision is excess over
coverage for the newly acquired or any other collectible insurance.
formed organization is excluded either
by the provisions of this coverage form
or by endorsement.
CA990187 0715 Includes Copyrighted Material of Insurance Services Offices, Inc. Page 1 of 5
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D. Limited Automatic Towing Coverage G. "Personal Effects" Coverage
Item 2.Towing, of Paragraph A.Coverage, Item 4.Coverage Extensions of Paragraph
under SECTION III—PHYSICAL DAMAGE A. Coverage, under SECTION III-
COVERAGE is amended to read: PHYSICAL DAMAGE COVERAGE,is
amended to add:
2. Towing
"Personal Effects" Coverage
We will pay for towing and labor costs
each time that a covered"auto" is We will pay actual cash value for"loss"to
disabled. All labor must be performed at "personal effects"of the"insured"while in
the place of disablement of the covered a covered"auto"subject to a maximum
"auto". limit of$2,500 per"loss", for that covered
"auto"caused by the same"accident". No
a. The limit for towing and labor for deductible will apply to this coverage.
each disablement is$500; H. "Downtime Loss" Coverage
b. No deductible applies to this cover-
age. Item 4. Coverage Extensions, of
Paragraph A. Coverage, under SECTION
E. Item 3. Glass Breakage—Hitting A Bird III. PHYSICAL DAMAGE COVERAGE, is
Or Animal—Falling Objects or Missiles of amended to add:
Paragraph A.Coverage under SECTION III
—PHYSICAL DAMAGE COVERAGE, is "Downtime Loss" Coverage
amended to add: We will pay any resulting "downtime loss"
Glass Repair Coverage expenses you sustain as a result of a
covered physical damage"loss"to a
We will waive the Comprehensive covered "auto" up to a maximum of$100
deductible for Glass, if one is indicated on per day, for a maximum of 30 days for the
your covered"auto", for glass repairs. We same physical damage"loss", subject to
will repair at no cost to you, any glass that the following conditions:
can be repaired without replacement,
provided the"loss" arises from a covered a. We will provide"downtime Noss" beginning
Comprehensive"loss"to your"auto". on the 5 day after we have given you
F. Increase Of Transportation Expense our agreement to pay for repairs to a
Coverage covered "auto and you have given the
repair facility your authorization to make
Subpart a.Transportation Expenses of repairs:
Item 4.Coverage Extensions of Paragraph b. Coverage for"downtime loss" expenses
A.Coverage under SECTION III— will end when any of the following occur:
PHYSICAL DAMAGE COVERAGE is
amended to read: (1) You have a spare or reserve"auto"
available to you to continue your
a. Transportation Expenses operations.
We will pay up to$50 per day to a (2) You purchase a replacement"auto".
maximum of$1,000 for temporary
transportation expense incurred by you (3) Repairs to your covered"auto" have
because of the total theft of a covered been completed by the repair facility
"auto"of the private passenger type. and they determine the covered
We will pay only for those covered "auto"is road-worthy.
"autos"for which you carry either (4) You reach the 30 day maximum
Comprehensive or Specified Causes of coverage.
Loss Coverage or Theft Coverage. We
will pay for temporary transportation
expenses incurred during the period
beginning 48 hours after the theft and
ending, regardless of the policy's
expiration, when the covered"auto"is
returned to use or we pay for its"loss".
CA990187 0715 Includes Copyrighted Material of Insurance Services Offices,Inc. Page 2 of 5
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I. Item 4. Coverage Extensions, of d. Contraband or property in the course
Paragraph A. Coverage, under SECTION of illegal transportation or trade.
Ill. PHYSICAL DAMAGE COVERAGE, is e. "Loss"caused by theft, unless there is
amended to add: evidence of forced entry into the
We will pay any resulting rental covered "auto"and a police report is
reimbursement expenses incurred by you for filed.
a rental of an "auto" because of"loss"to a K. Accidental Airbag Discharge Coverage
covered "auto" up to a maximum of$100 per
day, for a maximum of 30 days for the same Item 3.a. of Paragraph B. Exclusions under
SECTION III—PHYSICAL DAMAGE
physical damage"loss", subject to the
following conditions: COVERAGE is amended to read:
a. We will provide rental reimbursement a. Wear and tear, freezing, mechanical
incurred during the policy period or electrical breakdown.The
beginning 24 hours after the"loss"and exclusion relating to mechanical
ending, regardless of the policy break-down does not apply to the
expiration,with the number of days accidental discharge of an air bag.
_ reasonably required to repair or replace L. Loan or Lease Gap Coverage
the covered"auto". If the"loss"is Paragraph C. Limit Of Insurance under
caused by theft, this number of days is SECTION III—PHYSICAL DAMAGE
the number of days it takes to locate the COVERAGE is amended to add:
covered"auto" and return it to you or the
number of days it takes for the claim to If a covered"auto" is owned or leased and
be settled,whichever comes first. if we provide Physical Damage Coverage
b. Our payment is limited to necessary and on it, we will pay, in the event of a covered
actual expenses incurred. total"loss", any unpaid amount due on the
lease or loan for a covered "auto", less:
c. This coverage does not apply while a. The amount paid under the Physical
there are spare or reserve"autos" Damage Coverage Section of the
available to you for your operations. policy; and
d. If a"loss" results from the total theft of a b. Any:
covered"auto" of the private passenger
type,we will pay under this coverage (1) Overdue lease or loan
only that amount of your rental payments including penalties,
reimbursement expenses which is not interest or other charges
already provided for under the Physical resulting from overdue
Damage Coverage Extension. payments at the time of the
J. "Personal Effects" Exclusion "loss";
Paragraph B. Exclusions under SECTION (2) Financial penalties imposed
Ill—PHYSICAL DAMAGE COVERAGE, is under a lease for excessive use,
amended to add: abnormal wear and tear or high
mileage;
"Personal Effects" Exclusion (3) Costs for extended warranties,
We will not pay for"loss"to"personal Credit Life Insurance, Health,
effects"of any of the following: Accident or Disability Insurance
a. Accounts, bills, currency, deeds, purchased with the loan or
evidence of debt, money, notes, lease;
securities or commercial paper or (4) Security deposits not refunded
other documents of value. by the lessor; and
b. Bullion, gold, silver, platinum, or other (5) Carry-over balances from
precious alloys or metals; furs or fur previous loans or leases
garments;jewelry; watches; precious
or semi-precious stones.
c. Paintings, statuary and other works of
art.
CA990187 0715 Includes Copyrighted Material of Insurance Services Offices, Inc. Page 3 of 5
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M. Aggregate Deductible (3) An "executive officer"or director, if
Paragraph D. Deductible under SECTION you are a corporation;
III—PHYSICAL DAMAGE COVERAGE is (4) A manager or member, if you are a
amended to add: limited liability company;
Regardless of the number of covered (5) Your insurance manager, or
"autos"involved in the same"loss", only (6) Your legal representative.
one deductible will apply to that"loss". If
the deductible amounts vary by"autos", P. Waiver Of Subrogation For Auto Liability
then only the highest applicable deductible Losses Assumed Under Insured Contract
will apply to that"loss". Item 5.Transfer Of Rights Of Recovery
N. Diminishing Deductible Against Others To Us of Paragraph A.
Paragraph D. Deductible under SECTION Loss Conditions under SECTION IV—
BUSINESS AUTO CONDITIONS is
III—PHYSICAL DAMAGE COVERAGE is amended to read:
amended to add:
Any deductible will be reduced by the 5. Transfer of Rights of Recovery
percentage indicated below on the first Against Others To Us
"loss"reported during the corresponding If any person or organization to or for
policy period: whom we make payments under this
Coverage Form has rights to recover
damages from another, those rights are
Loss Free Policy Periods Deductible transferred to us. That person or
With the Expansion Reduction on the organization must do everything
Endorsement first"loss" necessary to secure our rights and must
1 o% do nothing after an"accident" or"loss"
2 25% to impair them. However, if the insured
has waived those rights to recover
3 50% through a written contract,we will waive
4 75% any right to recovery we may have
5 100% under this Coverage Form.
If we pay a Physical Damage"loss" during Q. Insurance is Primary and
the policy period under any BUSINESS Noncontributory
AUTO COVERAGE FORM you have with Subpart a. of Item 5. Other Insurance of
us, your deductible stated in the Paragraph B.General Conditions under
Declarations page of each such SECTION IV—BUSINESS AUTO
COVERAGE FORM will not be reduced on CONDITIONS is amended to read:
any subsequent claims during the remainder a. This insurance is primary and
of your policy period and your deductible
reduction will revert back to 0% for each noncontributory, as respects any other
such COVERAGE FORM if coverage is insurance, if required in a written
contract with you.
renewed.
O. Knowledge of Loss and Notice To Us R. Other Insurance—Hired Auto Physical
Damage
Subsection a. of Item 2. Duties In the Event Subpart b. of Item 5..Other Insurance of
of Accident, Claim, Suitor Loss of
Paragraph A. Loss Conditions under Paragraph B. General Conditions under
SECTION IV—BUSINESS AUTO
SECTION IV--BUSINESS AUTO
CONDITIONS is amended to add: CONDITIONS is amended to read:
However, prompt notice of the"accident", b. For Hired Auto Physical Damage
claim,"suit"or"loss"to us or our Coverage, the following are deemed
authorized representative only applies to be covered "autos"you own:
after the"accident", claim, "suit" or"loss"is (1) Any covered "auto"you lease,
known to: hire, rent or borrow; and
(1) You, if you are an individual;
(2) A partner, if you are a partnership;
CA990187 0715 Includes Copyrighted Material of Insurance Services Offices, Inc. Page 4 of 5
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(2) Any covered "auto" hired or rented
by your "employee" under a
contract in that individual
"employee's"name, with your
permission, while performing
duties related to the conduct of
your business.
However, any"auto"that is leased, hired,
rented or borrowed with a driver is not a
covered"auto".
S. Unintentional Failure To Disclose
Hazards
Paragraph B. General Conditions under
SECTION IV—BUSINESS AUTO CONDI-
TIONS is amended to add:
9. Your failure fo disclose all hazards
existing as of the inception date of this
policy shall not prejudice the coverage
afforded by this policy, provided that
such failure to disclose all hazards is not
intentional. However, you must report
such previously undisclosed hazards to
us as soon as practicable after its
discovery.
T. Additional Definition
SECTION V—DEFINITIONS is amended to
add:
"Personal effects"means personal
property owned by the"insured".
"Downtime loss" means actual loss of
"business income"for the period of time
that a covered "auto":
1. Is out of service for repair or
replacement as a result of a covered
physical damage"loss"and
2. Is in the custody of a repair facility if
not a total "loss".
"Business Income"means:
1. Net Income (Net Profit or Loss
before income taxes)that would
have been earned or incurred; and
2. Continuing normal operating
expenses incurred, including payroll.
In this endorsement, Headinos and Titles
are inserted solely for the convenience and
ease of reference. They do not affect the
coverage provided by this endorsement,
nor do they constitute any part of the terms
and conditions of this endorsement. All
other policy wording not specifically
changed, modified, or replaced by this
endorsement wording remains in effect.
CA990187 0715 Includes Copyrighted Material of Insurance Services Offices, Inc. Page 5 of 5
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BLANKET WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT
This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different
date is indicated below.
(The following "attaching clause" need be completed only when this endorsement is Issued subsequent to preparation of the policy).
This endorsement, effective 12:01 AM 03/01/2019 forms a part of Policy No. WC 012-33-2162
Issued to BERG & ASSOC I ATES INC
By THE INSURANCE COMPANY OF THE STATE OF PENNSYLVANIA
We have a right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce
our right against any person or organization with whom you have a written contract that requires you to obtain this
agreement from us, as regards any work you perform for such person or organization.
The additional premium for this endorsement shall be 2.00 % of the total estimated workers compensation premium
for this policy.
WC 04 03 61 Countersigned b _
(Ed. 11/90)
Authorized Representative